Healthcare Provider Details

I. General information

NPI: 1336079961
Provider Name (Legal Business Name): MIKAYLA SANFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6520 DOUBLE EAGLE DR UNIT 620
WOODRIDGE IL
60517-1586
US

IV. Provider business mailing address

6520 DOUBLE EAGLE DR UNIT 620
WOODRIDGE IL
60517-1586
US

V. Phone/Fax

Practice location:
  • Phone: 773-865-5414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: